Erin: 0:12

Hello and welcome to another episode of About Sustainability... This is Erin, one of your co-hosts. We are charging on with our series on the Sustainable Development Goals or SDGs. And this time, we talked about SDG3 on Good Health and Well-Being. I was joined by two co-hosts, André and Bob, and our guest, Eric Zusman, whose voice you may have heard on a previous episode on the Intergovernmental Panel on Climate Change. Eric works on a lot of different things, but he is passionate about improving air quality and mitigating climate change, both of which are crucial public health topics. We started the conversation off with what it means to be healthy and what is required to attain good health. We then moved on to what SDG3 emphasises and what it doesn't, global progress on the goal, and the impacts of COVID-19. By the way, you'll hear me make a point about a majority of deaths these days being caused by non-communicable diseases, which are basically diseases that are not infectious, even in developing countries. Now, this is true, but in the poorest countries of the world, the burden of communicable diseases is greater than non-communicable diseases, skewed to a large extent by health outcomes in Africa. So... This is just to add a little more nuance to the discussion. So after discussing SDG3 generally, we looked more deeply into air pollution, an environmental exposure that is responsible for 7 million premature deaths annually. We explored linkages with climate change, co-benefits solutions that achieve air quality, climate mitigation and health objectives simultaneously, and the challenges or tradeoffs of implementing such solutions. In this episode, there's a lot we covered, but also a lot we couldn't, like other environmental determinants of health and the linkages between climate change and health more generally. Still, I hope that this conversation gets you as excited about public health as I am and gets you thinking about the challenge of ensuring healthy lives and promoting well-being for all at all ages. Today, we're going to talk about SDG3, which is on health. The goal is titled "ensure healthy lives and promote well-being for all at all ages". And that seems like a very ambitious goal, but first, I'd like to discuss what it really means to lead a healthy life. What does that mean?

Eric: 2:54

Thanks a lot, Erin, for introducing this and starting this off with the link. What is a really interesting question and interesting way of talking about SDG3. And I think what makes it so interesting is that usually when we think about what it means to lead a healthy life, we think about disease or some of the immediate threats to health. And of course, those are still quite relevant and quite important, especially as it relates to, for instance, the health of children or maternal health and whatnot and diseases- communicable diseases... But I think what we see with SDG3 is, for lack of a better term, a more expansive view of what it means to be healthy. And this is evident, for instance, in the fact that SDG3 also puts some emphasis on mental health and also a lot of emphasis on thinking about well-being and also thinking a little bit about some of the things that you as an individual and also as collectives, as governments, need to do to to achieve, you know, good health, both in a conventional sense and more focusing on some of the mental dimensions. For instance, one of the targets on SDG3 is on universal health coverage.

Erin: 4:24

Right.

Eric: 4:25

And I think this is quite in some ways progressive, forward looking, aspirational, what have you. So I think the nice thing about the SDGs in general and this SDG specifically is it sets up a new set of norms, if you will, on what it means to be healthy and what you need to do to achieve that. So I think that's quite a nice feature of the SDG. And also of course we'll relate more towards some of the environmental issues - environmental health issues that we'll deal with later in the podcast.

Erin: 4:55

Yeah, that's a really good point. Actually, the World Health Organization (WHO) Constitution states or defines health as"the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". So in that sense, you know, it's not really about whether or not you get this disease, but it's about whether you truly feel that you are healthy and truly feel like you can thrive in society. But actually, I have to say, the way that the targets- maybe we'll discuss this a bit later- but the way that the targets and indicators are framed, I feel like they're still looking at really the absence of disease or tracking those aspects more so than encouraging healthy behaviours or healthy systems and so forth. So I thought that was quite interesting.

André: 5:47

Mm hmm.

Bob: 5:48

I just wonder if it makes sense to quickly read through what the targets are. So Target 3.1 is reduce maternal mortality. 3.2 is end all preventable deaths under five years of age. 3.3 is to fight communicable diseases. 3.4 is to reduce mortality from non-communicable diseases and promote mental health. 3.5 is to prevent and treat substance abuse. 3.6 is to reduce road injuries and deaths. And then we have universal access to sexual and reproductive care, family planning and education; achieve universal health coverage; reduce illnesses and death from hazardous chemicals and pollution; implement the WHO Framework Convention on Tobacco Control; support research development and universal access to affordable vaccines and medicines; increase health financing and support health workforce in developing countries; and finally improve early warning systems for global health risks. I read the summaries of the target texts from globalgoals.org and not the actual target text. So for anybody reading along, it may be different.

Erin: 6:58

Mm hmm.

André: 6:59

That's a lot, hey?

Eric: 7:00

Yeah. Yeah, yeah.

André: 7:01

Well-

Bob: 7:02

Pretty broad.

André: 7:03

Well, I was just going to ask, what- if any of you guys have any idea what they mean by social well-being? You read it in the WHO-

Erin: 7:10

Yeah-

André: 7:10

That sounds like a very nebulous concept to me, but any idea?

Erin: 7:14

I think it pertains to the loneliness epidemic. So essentially, you know, how people have different ties and connections... I guess has the underlying assumption that people need to be around other people to feel ultimately mentally and physically well. So.... How that is defined is a lot more nebulous, like you said. You know, it's not like with physical health - it's very clear, you know, what the outcome is. Mental health, less so, but still, there are some clinical criteria in some cases. But with social health, you know, some people are totally fine being on their own and then other people are really not fine with that. So there's a range. Yeah.

Eric: 7:54

I think it's interesting. I think that there's a perhaps another dimension of this too, and that I mean, I think the social connectivity is part of the story, but I think that there's - you know, and this is also a nebulous concept, too - but I think there's a growing amount of work on just happiness and whether or not people feel content, not necessarily connected to a broader community, but fulfilled with themselves and what they're doing and whatnot. When I was doing a little bit of background on this, I was looking at the Sustainable Development Solutions Network (SDSN). So this is an initiative that has started in parallel with the SDGs and taking a lot of the impetus from Jeffrey Sachs. And they track how countries are doing on the SDGs. There was, in their tracking for this SDG, there's actually like an index on... Maybe it's well-being or maybe it's happiness, but it's like a broader index that they're using to look at how countries are doing on some of the less quantifiable dimensions of this, but- so I think it's, you know, it's partially social connectedness, but I think it's also having some just a sense of happiness and feeling fulfilled.

André: 9:12

Just a quick overarching point, which I think now is the right time to make this, and that might be not all that accurate, but I think just as a very general rule, the lack of physical well-being is more of a challenge in the developing world, and mental well-being, or lack thereof, is more of a challenge or at least a focus in the developed world. And I think part of the reason- well, part of the reason for the former- the main reason for the former goes back to poverty, I guess. And the main reason for the latter, I think is - and again, this is very broadly speaking - but is is largely that the changes in society that come along with developed environments. One of those changes is that is less contact with other people and less of a social atmosphere. And I'm thinking of South Africa where I grew up, as has these two worlds living very much side by side. And I- something that I've noticed spending time in the poorer parts of the country, something that's very quickly evident is the vibe, you know? How much interaction there is between people. And I'm sure there are, you know, mental health issues in those communities. But there's such a strong social vibe and, of course, there are social problems as well. But I think that I can sort of see why mental well-being is more of an issue in more cloistered societies than than those. So I'm really putting myself out there because I'm far from an expert in this area. This is more of an anecdote than anything else, but maybe just to set the scene a little bit.

Erin: 10:41

Yeah, I definitely agree that mental health is, I guess maybe more talked about, perhaps, in the developed world, although I can say that, maybe the way that we conceptualise disease in a conventional sense is mostly communicable disease. And in that sense, of course, you know, we have a lot of the Global South still suffering from, you know, things like malaria,[tuberculosis] (TB) and so forth. And there's a lot of money, actually, that goes into these programs. So we feel like, you know, there's a lot of issues around that. But then, when we think about the majority of deaths now, they're actually caused by non-communicable diseases around the world. And I can't really tell you what the distribution of that is, but I suppose that that happens a lot in the Global North as well as the Global South. So it's very interesting. I think it's also because it's a lot more difficult in terms of, you know, understanding the causal pathway and prevention and treatment of things like diabetes or cancer or heart disease.

André: 11:46

The non-communicable diseases.

Erin: 11:47

Right. Exactly. Yeah. And one other, I guess statistic is that it actually varies quite a bit depending on the age. So age ranges. So if you look at under five, so like babies essentially, a lot of deaths happened due to communicable diseases. So things like diarrheal disease, for example. But then when you look at it from 5 to 14 or 14 to 49 or something like that, it shifts to other types of- well, non-communicable diseases become much more prominent. And then, of course, there are also sex-based [differences]. So particularly for 14 to 49 or something like that, males tend to have a much greater mortality rate for injuries and roadside accidents as opposed to females.

Eric: 12:41

Can I ask a quick question ? And I think this is a really good point. Do you think that the- and Bob read off some of the targets - do you think that SDG3 does a good enough job of taking into consideration some of these differences across age groups, across gender? Or could there be more of an effort to capture some of these differences, do you think?

Erin: 13:06

Yeah, thank you for that question. I do think that they do, implicitly- so there is a specific target for traffic accidents. So, you know, you're really speaking to a certain group. Right? Although it's not really explicit. And there is another target about reproductive and sexual health. So that's also speaking to a different group, although, of course, everyone can play a role in that - it's not just women and girls. So there are elements of, you know, at least with sex- based differences or disparities, they do consider those. But I feel that- I guess this is a legacy of the MDGs (the Millennium Development Goals), but a lot of it is still based around the communicable diseases like HIV, malaria and TB and so forth. And there is some discussion of non-communicable disease, but none of it is really that explicit on certain age ranges... Yeah.

André: 14:06

It's just a small question slash correction. You mentioned malaria as a communicable disease, but I don't think it is, right? Because it can't be passed from one person to another. So maybe the question would be, what is a communicable disease? Because it can be communicated by a vector, but the vector is not a human being. So I would have thought malaria as a non-communicable disease.

Erin: 14:30

Yeah. So actually communicable diseases, I think, include vector borne diseases.

André: 14:35

Okay.

Erin: 14:35

Yeah-

André: 14:36

Oh, I didn't know that. Okay.

Bob: 14:37

I was really surprised to find reduce road injuries and deaths in there. It seems to be kind of different than all the other targets and the way you might approach fixing it also seems a lot different than all of the rest of them. There- they seem to be... You might change health policy or you might change the distribution of access to health services or health products for maintain the other ones, but for road injuries and deaths... I'm curious how that fits in. I don't know if anybody's research has turned up anything.

André: 15:14

I guess it's just the numbers, right? It's simply because it's such a high mortality area. But that's just my speculation.

Erin: 15:21

Yeah. No, I think that's it, yeah. I think they basically pulled out the most common causes of death for each maybe group or, you know, like strata and then determined- well, at least for males in of a certain age, you know, that is a really big issue. And traffic accidents are... You know, we don't really talk about them that much, but there's certainly a prominent cause of death. So yeah.

Eric: 15:49

Several years ago, we did a lot of work on looking at the impacts of different policies in the transportation sector. And we did a lot of work on this theme of co-benefits, which I think we'll come back to later in this podcast. Of course, the air pollution story is quite prominent. So, you know, if you introduce different interventions in the transport sector, it can reduce air pollution. That has big health impacts. But I also remember that one of the other big impacts was the traffic accidents. And there been a lot of interest and growing amount of research - this is about ten years ago or so on - estimating these impacts. And so I suspect that, you know, that has caught the attention of both the health and the transport community. But the other thing that I think that is also interesting and also points to one of the issues that Bob raised is, in some ways, it does feel a little bit out of place in this in this goal framework. But, you know, the one of the things that's missing from the SDGs is that there's no goal on sustainable transport or sustainable mobility. And so my intuition is that, you know, they put this in SDG3 and also I think there's some indicators and targets on sustainable transport under SDG 11 on sustainable cities and communities. But the absence of having a goal on sustainable mobility- I know some in the sustainable transport community were pushing for having, you know, their own headline goal - is part of the reason you get this here.

Erin: 17:23

Interesting.

Eric: 17:24

Yeah. Yeah. But I think part of the challenge is, I don't know if the health community necessarily has all the answers to this this issue. So that's- in some ways, this health goal was a little bit cobbled together in some places. Yeah, yeah.

Erin: 17:39

Yeah. That's very true. I think- I'm personally very interested in systems and how the built environment or other types of environments shape the health, lifecourse of an individual or a group of individuals. And I felt like a lot of the targets and indicators - maybe this is a critique of the current goal as it stands- don't really... They're looking at these outcomes, right? Mortality due to X or number of people living with Y and not really looking at, you know, what is kind of the underlying systemic, I guess, solution or cause behind these conditions. And of course, you know, this is not something that the health community or like the medical community can necessarily do much about. Like, for example, with urban health, you would have to really restructure the way people live and where people work and what... how they play or how they spend their time and all that. So that's not really something that the medical community can do that much about. But still, it just, to me, feels like a fundamental piece is missing from this goal.

Eric: 18:57

So I like this comment, Erin, and I agree with you wholeheartedly. And so I want to follow up on it, but I also want to come back at you and everybody with a question on this. So I also feel like that the systems piece is missing here to some extent. I think it's not only the health goal, but I think in many of the goals, the SDGs, interconnections are under emphasised perhaps or understated. And part of that is, I think, as you rightly point out, I don't know if the health community can necessarily support the built environment or redesign the built environment, but I think there could be more of an effort to make those connections within the goal perhaps and, you know, point to ways that the health community could work with the sustainable urban environment community, etc., etc.. Having said that, so if we had a redo at the design of SDG3, is there anything specifically that you would want to put in or take out for that matter? Or... I just want to preface this by saying, like, for instance, that the folks at SDSN and I think also folks from IIASA, this is the International Institute for Applied Systems Analysis in Austria. Their The World in 2050 initiative- they have this initiative to look at what the world should look like in 2050. When they thought about the SDGs, they've put forward six necessary transformations and one of the transformations is basically modernising health systems with a strong emphasis on universal health coverage, but they don't necessarily bring in some of the other elements to that, to that core. So there's a systems element. But some of the other things like for instance, traffic accidents are not necessarily there. So I guess my question is, is there anything that's missing or anything that could be revised if we had to do this again?

Bob: 20:54

I was surprised to see that suicide is not in there explicitly, although mental health is covered, you know, suicide is not explicitly called out as one of the targets, which was surprising to me.

Erin: 21:05

Actually it is an indicator. But...

André: 21:08

It's an indicator.

Erin: 21:09

Yeah. But again, you know, one I guess additional critique of that before we move to Eric's question- very big question on, you know, what is, you know, how do we redesign SDG3... Is that there is, you know, depression and anxiety. There are other things that people live with that, you know, don't necessarily- I mean, they could lead to death, but, you know, death isn't the only outcome that we should be concerned with. Right? Yeah. So that's, I guess, another critique that I have of this in terms of measurements.. Yeah, I think it matters that we know who is living with it in addition to who's dying of it, if that makes sense.

Eric: 21:48

Yeah. That's a very good point.

André: 21:51

It's the drivers and the effects of this, too. And that's- it just reminds me of the traffic accident thing where the the effect is very much health related, but the driver has nothing to do with health, really.

Erin: 22:02

Exactly.

André: 22:02

Yes, it is a- I agree it's a bit of a strange one to have in there, the traffic accident one.

Erin: 22:08

Yeah. So any thoughts on Eric's question? Wow. So that's a fundamental one, isn't it?

André: 22:14

About what- what should have been included that wasn't included?

Erin: 22:18

Yeah. Yeah. I mean, if I could... I mean, of course, this is not comprehensive, but just an idea to put out there- just as you were saying about transport, right? Given how many people live in cities now, you know, the emphasis on cities and how we build healthy cities should be really present here, which I think is present more in SDG 11 than this [goal]. So for SDG3, I would say that there should be more of a framing around how to make parks, for example, more accessible for physical activity or, you know, air pollution mitigation; sustainable transport, again, also very important for air pollution; safe water.... Water is also a huge issue, and I guess that's already covered by, you know, SDG6, I think, to some extent. But again, another fundamental thing that we need to have. And then of course, I'm glad that they included universal health coverage and retention of the health workforce, because, again, that is really, really important. And I think we've seen the issues really- well, I guess the vulnerability of our health workforce in the past few years. And appreciating the people who actually work in this space, I think also should be more prominent going forward. Yeah. So just a few ideas. Of course, not comprehensive, but... Yeah

Eric: 23:46

Yeah. It's... It's difficult to think about, you know, the hypothetical or the counterexample. But I think, let's just say if we're going to do the SDGs again in 2025, of course, we're- you know, 2030 is supposedly the expiration date of the SDGs. And I think, you know, in the next year or two, actually, we'll probably start thinking a lot more about future SDGs. But I think one thing that would probably appear in a future SDGs would be something on pandemics or, you know, something on major global health crises, although I don't know exactly how that would be structured. But, you know, obviously, given the COVID experience, I think that would be something that would be prominent, basically. And I have a feeling that, you know, some of the issues on the- mental health I think would be- and wellbeing... I think those would also perhaps be more prominent. But yeah, those are just some some quick observations or some quick thoughts.

Erin: 24:49

And in addition to pandemics, climate change, right?

Eric: 24:53

Yeah, yeah, yeah. For sure. For sure.

André: 24:56

I was just going to say that education- I mean, education is fairly prominent throughout the SDGs and it is mentioned once under the targets, Target 3.7, one of which is actually the universal healthcare related one. But I think that it's under emphasised in general across the SDGs and I think that's the case for SDG3 as well. I guess- it's a foundational must-have that could be emphasised more. And I guess I haven't- I'm not as familiar with indicators as I as I should be, there may be a bit more in there -but if I were in charge, then there'd be more about education. Yeah.

Erin: 25:35

Yeah. No, it's super important. Right? And I think like another prominent thing that I guess is kind of missing here is that the SDGs, I assume are global goals, but implemented at the national or local level. And well, at least having grown up in the Philippines, there was a lot of anecdotal, I guess stories about a lot of Filipino doctors leaving the Philippines and going somewhere else to earn more money. And so this issue of brain drain is also really important. And I think, you know, retention of the health workforce really means, you know, creating an environment that- you know, a financial or whatever working environment that is good enough for people or to stay, I guess. Yeah. It's not just... Yeah. I mean, in addition to having the proper education, I think it's about creating that working environment that works for everyone.

André: 26:35

Mm hmm.

Eric: 26:36

I mean, I fully agree with this. And, I mean, I think one of the other things that we've seen, if I keep on harping on the COVID issue, but the COVID is a health crisis that's made it more challenging to deal with other crises, to keep good people working on health. You know, it's led to reductions in workforce and labour retention. And so there's like this sort of multiplier effect that can- some of these crises can have on to the other parts of the- So for instance, like I remember reading that, you know, there have been significant gains in reduction in cases of TB(of tuberculosis), which is, you know, part of the goal. But a lot of those gains or the improvements have been diminished significantly by COVID. And to personalise this a little bit more, I have a good friend who lives in southern India. She has a condition where she needs to go see a doctor who is about 5 hours away from her house. Because of COVID, she couldn't go. I mean, it was just not feasible to go. And this is also in some ways- I mean, it's also been exacerbated by climate change because southern India has been hit by heat waves and sudden rain. And so I think these interactions between some of the effects within the health goal and then some of the environmental health impacts also made it more difficult to achieve some of the sort of more conventional parts of the goal that were also part of the MDG structure, too.

Erin: 28:14

Yeah, that's such a good point.

Eric: 28:16

Yeah.

André: 28:17

Also, you know this, I'm always going on about tradeoffs, but I think that this illustrates a really massive way in which the whole world has become familiar with, and that is this kind of balancing act between treating COVID for- responding to COVID for health reasons and responding to COVID for economic reasons or reasons of keeping the economy going. And, you know, I think the arguments about the degree to which that was addressed successfully, that will continue for decades still, probably. But it seems like, you know, it's a discussion worth having. It's not necessarily always the right thing to do to segregate people and prevent them from having any contact with each other if that means that it results in economic ruin, because economic ruin has you know, it causes lost lives further down the line. Right? It's just more indirect. So I know this is a very controversial topic, just to point out that this brings up one of those unfortunate trade- offs which we're probably still learning how to handle.

Erin: 29:20

Yeah, I think that's a key point because at least in public health, we learned that socioeconomic status is a fundamental cause of health outcomes. So if we think about these systemic conditions, right, that create good health or bad health for someone or create vulnerabilities, I think to that extent, we really have to think carefully about what types of policies we employ. And just to add to like isolation, for example, again, we talked about mental health, right? And that's been a huge issue for a lot of people everywhere, you know. Traditional approaches- I mean, this is a very traditional- like quarantining, self-isolation is a very traditional, paternalistic public health intervention. And that's usually how we do it until like vaccines come around, I guess? But I mean, in this case, even if the vaccines have come around, you know, implementation has been an issue and variants and so forth. So it's not as easy, I guess. It's not as easy as in the textbooks. Yeah.

Eric: 30:34

I mean, I read somewhere that the impacts of COVID where this was, I think at the beginning of this year, so that the numbers have increased, but I think there were 5 million deaths worldwide due to COVID at the beginning of 2022. And... But the estimates were that there were three times those number of deaths due to the indirect effects of COVID. So 15 million deaths collectively.

André: 30:59

Wow.

Eric: 31:01

And so you're talking, you know, 10 million additional- ballpark figure, but 10 million deaths from disruptions due to COVID. And obviously, I'm sure there's a lot of debate over how you define what those indirect impacts look like. But the fact that we're talking twice the size of those impacts, I think gets to the heart of things. Yeah. Yeah. There are trade-offs and how do you design policy interventions given these this complexity policy is almost inherently a blunt instrument, right? So it's challenging to take into consideration all of those contextual factors.

Erin: 31:39

And just to add, you know, those numbers are shocking. But, you know, during this the past two and a half years, people have not really- people have been more reluctant to seek medical care for things that they might find. Maybe, you know, they found a lump somewhere, but they haven't been really been able to get the care that they need. Then, you know, you have another set of delayed diagnoses of certain illnesses or certain conditions. And so...COVID I think, you know, depending on how you measure it, disruptions and I mean, not necessarily covered per se, but certainly COVID- these types of disruptions to the health system really take a toll on not just those suffering from that particular illness, but on everyone.

Eric: 32:27

Mm hmm.

André: 32:29

Can I ask a very general question? What are the- and looking at physical health, you know, just health in the most sort of basic sense of the word- what are the biggest sort of the single biggest threats to physical health worldwide? And I know that that differs from place to place. But I remember reading a while ago that malaria, I think, is still the biggest killer as a single disease. Certainly more than COVID still, although I think there was some sign that COVID might overtake it. But I'm- I don't know if you guys have any knowledge of the figures there and others as well that are sort of particularly large problems.

Erin: 33:12

Sorry. Yeah. I don't have the numbers on like, you know... But I think malaria is definitely up there. One thing I can say is that what's tricky about like the treatment of non-communicable diseases that no single non-communicable disease has equivalent deaths as like the major communicable diseases like malaria, HIV or so on and so forth, right?

André: 33:32

But together-

Erin: 33:33

Together. Yeah, they really represent like the majority of premature deaths or disability-adjusted life years.

André: 33:39

Okay. But is that the case in the developing world as well? Even in the developing world?

Erin: 33:46

Yeah. Yeah, I think that is the case. But again, like I said earlier, you know, it really depends on age groups and, you know, certain segments of society as well. So for really just broad strokes, I think that is the case.

André: 33:59

Mm hmm. Okay.

Eric: 34:01

Yeah... I'm looking this up on right now, and...

Erin: 34:03

Oh yeah, well.

André: 34:04

I should've done it before this.

Eric: 34:05

No, no, no, no, no, no, no.

André: 34:07

I just- I would have thought that tuberculosis and malaria together killed more people in the developing world than all non-communicable diseases combined. But I stand under correction very much.

Eric: 34:23

Yeah. I mean, I'm just looking this up on Our World in Data. This is based on the Global Burden of Disease study, which is was published in 2019, and still has a really great database for all of this. So the greatest killer globally is cardiovascular disease(393.11 million), followed by cancer, followed by neonatal disorders, and then sort of all other non-communicable diseases.

André: 34:57

Okay.

Eric: 34:58

Interestingly, to come back to some of issues that we raised before, transport injuries are the 12th biggest and mental disorders our sixth biggest. Huh. So yeah, that says a lot actually. I mean that says- suggests part of the reason that's structured the way it is.

André: 35:22

Can I just ask that I- we covered the whole COVID complication factor quite thoroughly, I think. But do you think there's anything more to say about what we could be doing better or what progress- what progress looks like, I guess you could say.

Eric: 35:39

In terms of how we're doing on SDG3. I mean, all of this is really contingent on how you define progress, but, at a very high level, looking at the once again, this Sustainable Development Solutions Network assessment, things don't look great. Basically, in almost the whole world, challenges remain. And those challenges are, perhaps not surprisingly, most significant in developing countries and very broad strokes, the lower the level of development, the bigger the challenges. I think that's fair to say. Okay. So that's sort of the glass half empty view of the world, but the glass half full view of the world is that there has been significant progress, especially before COVID, on many of the health targets. And some of these, I think, reflect the fact that, as mentioned previously in the MDGs, there was a significant emphasis on health. So there were three different MDGs that were related to health. And so I think there's been some continued momentum from the MDGs. And I think health ministries have continued to focus on, for instance, maternal health or working on the impacts of malaria or tuberculosis. So the trends in some of the key countries like India, for instance, prior to COVID, were pretty promising, although, when you look at it at a sort of aggregate level, you might not see that as much, in part because the goals themselves are so aspirational. So it's a lot to expect developing countries to basically eliminate some of these diseases or to get to the place where the indicators are set. So I think that that's another side of the story. And then I think the third side of the story is, if you look at like the air pollution side on Target 3.9, it's pretty evenly split between- developed countries are pretty much on target to achieve 3.9; developing countries, not so much. But when you look at it a little bit finer grain of detail, part of the explanation for that - and this is something that, you know, one of folks is working with you on the podcast, Simon Olsen has highlighted - part of the explanation for that is because of these spillover effects. So a lot of countries have basically relied heavily on developing countries to manufacture goods and services. And this requires energy. And sometimes this energy is generated with fossil fuels. It also requires more transport and other activities. So I think there is an important argument to be made for greater efforts to harmonise and collaborate on especially health and then, you know, air quality improvements, environmental threats to health.

Erin: 38:35

Yeah. Maybe we can move on to the environmental determinants of health and maybe we can talk a bit about Target 3.9 "reducing the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination". And maybe Eric can talk a little bit about that?

Eric: 38:55

So thanks. Thanks a bunch on this one, Erin. And I mean, obviously, this is a very important target. And I mean, it's something that's, can I say, near and dear to my heart, because it's one of the three places that air pollution is reflected in the SDGs. In terms of the environmental threats to human health, it's the biggest one. I think it's really important that it's reflected in the SDGs. Having said that, and I'm going to be a little bit controversial here, I think it would have been better if there was a full headline goal on air pollution. I mean, I understand why this is where it is. The World Health Organization is the custodian agency for overlooking progress on the health impacts of air quality, both indoor and outdoor air pollution. But I think as a result of this, you don't have as much attention to the serious impacts of air pollution as you would if it had its own headline goal. So, you know, there are goals on, for instance, life on land and life below water, on climate change, and sustainable consumption and production, as well as cities where there's also an indicator on PM2.5 on particulate matter(fine particulate matter). But I think as a result of the fact that it's sort of spread out into different places within the SDGs, you don't get as much effort and attention to this as you would if it had its own headline goal. Yeah.

Erin: 40:36

Yeah, yeah. That's actually a really important point because I think, the way I understand how the messages were structured was that they had certain, I guess, cross-cutting issues in a few different places. So maybe air pollution was one of those. But I guess the trade-off is that there is less emphasis if it's kind of embedded in all these other goals. Yeah.

Eric: 41:02

Yeah. I think as a result of that, there's sort of two things that happened. One is perhaps most importantly, the voluntary national reviews- these are the reports that come from different countries on what they're doing on the SDGs. They tend to downplay air pollution or don't mention it so much. This is not across the board. But, you know, for instance, one of our colleagues, Mark Elder, just published a paper on different policies that were listed in Voluntary National Reviews from countries in ASEAN, and you would naturally assume that air pollution policies would be up there. But it was actually one of the policy areas that didn't get so much attention. And of course, you have, you know, water pollution and climate change and whatnot, but not having a headline goal, I think is problematic for, you know, what national policymakers are reflecting in their SDG plans. And it also has an impact on, you know, resource allocation and whatnot. And I think the other thing that gets neglected as a result of this is - and we talk a little bit about this in terms of health more generally - but is sort of the forward and backward linkages to other goals. So it's less likely that countries will start thinking about integration between air pollution and climate change because there's no headline goal on air pollution and there's nothing directly mentioned in the climate action goal that says anything about air quality. Can talk a little bit more specifically about why that's problematic, but those interlinkages, I think, get neglected when you don't have a headline goal. That's my main point.

Erin: 42:38

Hmmm. André?

André: 42:39

Yeah. I just wanted to make another point about trade-offs and to do with air pollution, indoor air pollution, which is kind of one of the areas that you look at most, right, Eric, which as far as I understand is caused mostly by wood burning stoves. Is that just- am I limiting my understanding to Africa? Or is that kind of applicable across the board?

Erin: 42:58

I think that's- Yeah, it's mostly cookstoves. Yeah.

André: 43:02

Right.

Eric: 43:02

Yeah.

André: 43:03

Right. So with the trade-off here, with the kind of some contention is that, that's a renewable resource that's being used for heat and for cooking that which is causing incredible health problems. Eric, can I quickly ask you, do you know what the global numbers are for deaths by indoor air pollution per year? Do you have any idea?

Eric: 43:23

Yeah, don't quote me on the exact exact figures, but I think overall it's, you know, 7 million premature deaths per year from air pollution. 4.2 is coming from ambient, so that's primarily outdoor air pollution, although it's tough to draw a line sometimes. And 2.8 is coming from indoor air pollution.

André: 43:43

Okay.

Eric: 43:44

And as you suggested, the vast majority of the course, the indoor air pollution is the-

André: 43:50

Wood burning stoves.

Eric: 43:51

Yeah. And in developing countries.

André: 43:53

Right. Right.

Eric: 43:55

You know, Africa and South Asia and, to some extent, Southeast Asia and Central Asia. Yeah.

André: 44:02

Thanks a lot for filling that in. So the tradeoff that I wanted to kind of just maybe ask you about and ask about solutions is that, you know, this is a renewable resource that's being used. And the argument is- and it seems pretty convincing- that the quickest way to get clean energy to those people, energy that's not going to put them at direct risk of pollution, is fossil fuel-based energy. And I know that there are lots of initiatives to get solar panels on roofs and that kind of thing, but that's a lot more difficult, and it's going to take a lot longer than connecting them to an existing grid, which is in the vast majority of cases, fossil fuel-run. So I just wanted to kind of 1) point that out and 2) ask you if there are sort of any lights on the horizon as far as that's concerned.

Eric: 44:50

Yeah. So I think there are some trade-offs there. There's no question about it. And I think, you know, part of the story is, right, that you want to try to get people to LPG or electricity-

André: 45:03

That's gas, right?

Eric: 45:05

Yeah, yeah. LPG, liquefied petroleum gas, to some extent as quickly as possible. Although as you also intimated, there are some decentralised renewable solutions out there, as well as some efforts to, for instance, use biogas and biodigesters, which are perhaps more sustainable alternatives. But you would also hope that, simultaneously, there would be broader shifts within the energy structure to more renewable, you know, to the shift away from, you know- So if you electrify that, you would then also rely more on large-scale solar installations or eventually wind power or hydropower, or what have you. So it's- you're right to highlight that there are some unquestionably some tradeoffs there. And it's not a perfectly seamless transition, André. But I think the hope is that, you know, with some mix of these different solutions, that the benefit calculus will weigh heavier on health and then that will hopefully- you'll get some catch-up with some of the energy transitions away from fossil fuels. Yeah.

André: 46:12

Just to kind of push you a little bit on that one- I don't know how much you know about this, but I'm thinking about, you know, an NGO probably based somewhere in the West in Europe or the US, or maybe Japan, that has sort of limited resources to bring clean energy to sort of maybe a village, you know, that kind of scale. And if they're an environmental NGO, they're probably going to try to get people to put solar panels in their rooms rather than trying to connect them to the grid. And I guess, like you answered the question very well there, but like in a real-life situation like that, which I've seen a few times in South Africa and neighbouring countries... Are they doing the right thing or should they be, how do you say, biting their fist for a while and giving those people what they need as quickly as possible and then working on the longer- term renewable solution.

Bob: 46:59

But wouldn't putting solar panels on the roof usually go along with connecting to the grid because solar panels providing standalone power to a house is a lot more complicated than- at least my understanding is, if it's not connected to the grid, it's a lot more complicated in some ways. Whereas if it- I mean because... Battery batteries are involved in that case, right?

André: 47:21

Yeah. And I don't know. I don't know. I'm just thinking of a couple of projects that I've seen. So I really don't know how representative they are. But yeah, the ones that I'm thinking of are sort of really low-budget projects where they've tiny batteries involved in that. Certainly there's no connection to the grid. But that's my-

Erin: 47:37

Electricity for lighting and that kind of thing?

André: 47:39

Yeah. Very basic stuff. Probably not even cooking actually. So I'm not sure how relevant this example is, even.

Eric: 47:44

If I can say maybe two quick comments on André's question and I have- Bob, I'm sorry, I have less response to your question, but for André's question, in my personal experience, what I've seen is there's two things. One is that the sort of- the NGO community that's had the most success where I've worked on these issues in Southeast Asia has actually focused more on not necessarily energy transitions, but just cleaner cookstoves. So stoves with fans on the bottom that help burn the biomass more efficiently, stoves that have some type of ventilation system so that you're not breathing in the particulates. And then-

André: 48:22

So it's even more low tech than the solar panels.

Eric: 48:26

Yeah. And then gradually perhaps moving from there to LPG or what have you. But on the NGO side, I think there's limited resources and they're also they have limited policy levers. Right? So a lot of times what they're doing is working with communities to educate them on the impacts and then demonstrate the improvements from improved cookstoves. And then also, I mean, the thing that's helped them....- because it's also been even a challenge to get communities to transition to the improved cookstoves because they- they're not super expensive, but they're- they can be, you know, 2 to 3 times, 4 times, 5 times as expensive as just starting a fire or even more rudimentary versions - is setting up community-based businesses to manufacture the stuff and then creating sort of a value chain where people are involved in the manufacturing in terms of the end of the marketing and then-

André: 49:20

Creating sustainability, as you know, continuity, right?

Eric: 49:23

Right. That's right. Exactly. Exactly. And a lot of times these businesses are run by women. And so it helps to communicate, because a lot of times, the people are making decisions on the cookstoves are women, so it helps to communicate those benefits. So that's one piece of the story that I've experienced and seen some success with. And then the other piece that I think is important is in terms of the solar, like the mini-solar, what you're talking about is - I've just read articles on this, I haven't experienced it personally, but there's been a lot of struggle to get some uptake on these programs. And one of the ways that they've found some success is to highlight and to demonstrate and to advertise or market the stoves, first and foremost, has a way for people to use cellphones and charge up their phones. So it's first and foremost about that communication.

André: 50:20

How does that work? How does it work, Eric?

Eric: 50:22

So there's an adapter on the stove or, you know, there's an adapter on the solar panel for charging phones basically as well.

André: 50:31

I see, I see.

Eric: 50:32

So it's multi-functional and communities that have had those adapters have done better with the stoves than communities that haven't.

André: 50:39

Wow, interesting.

Eric: 50:40

So those are some of the things that I've observed or read about and it makes sense in some ways.

Erin: 50:47

Yeah, I learned in graduate school that with respect to cookstove- related interventions, one key issue is stacking. So essentially, yeah, like you get a new improved cook stove, but you don't throw out the old one, you just get- you know, you could get double the amount of cooking done, I guess. So it's complicated. You know, people behave in unpredictable ways. Yeah.

Eric: 51:12

Yeah, yeah. This is very, very true. And yeah, that related to what Erin mentioned, it's partially a stacking story where you try to cook more. But also what I've understood is that the flavour from the older stoves are better. It has a sort of smokier flavour, you know, more barbecued. And so for certain dishes, they'll cook with the older cook stove and for certain dishes, cook with a newer one. And it's not so straightforward, basically to get people to turn away from technologies that they've depended upon for long periods of time.

André: 51:43

Hmm.

Eric: 51:44

Yeah, I mean, this is a little bit off track, but I'll just relay a story when we were doing some of this work on climate, gender, air quality in Southeast Asia. And then we had a really big meeting with an agricultural minister from a country in Southeast Asia. I'll leave it at that. And we were basically trying to persuade him that it would be good for women to get involved in climate mitigation activities by getting involved in these cookstove businesses. Or another business they had was manufacturing biodigesters. So he listened to our whole thing. And, you know, this guy was, you know, pretty astute and whatnot. And after we were all done, I mean, I was shaking the whole time. I was really nervous because I was like in the presence of this minister, blah, blah, blah. But he turned to us and said,"Yeah, but you know, if you start taking women out of the household, who's going to cook the food?"

Erin: 52:38

Gosh.

Eric: 52:38

"And who's going to take care of the kids. And especially, you know, when the men come home from the field, who's going to be there for them?" This is all to say that there's multiple interlocking issues here and that they're quite caught up in sort of cultural sensitivities and whatnot. And I was sort of astounded by this whole reaction at the same time as, you know, dumbfounded. I didn't really know what to say after that. It's sort of a nonstarter, basically.

André: 53:03

Hmm.

Erin: 53:05

Wow.

Eric: 53:05

And so it's does speak to some of the challenges of trying to change lifestyles in ways that are healthy, and especially when you're coming at it from an angle of, you know, changing international norms, it makes sense. But once you start bringing this down to different contexts and levels of decision-making, not that far actually from the international level - I mean, this was an agricultural minister, so - it becomes much more complicated.

Erin: 53:30

Hmm yeah. What a story.

Eric: 53:34

Yeah. I mean I think the other thing that is discouraging or not so useful about having the air quality issue in the health goal is that this linkage to climate change, right?

Erin: 53:45

Yeah. Oh, can you actually tell us more about that? What is the linkage between air pollution and climate change?

Eric: 53:51

Yeah, so there's a few of them actually. So one of them is, a lot of the sources of air pollution are coming from the burning of fossil fuels, which is also one of the key sources of climate change - of greenhouse gases, of carbon dioxide. So a lot of times when you burn fossil fuels, you'll create things like this fine particulate matter ([PM2.5]) that gets into your lungs and it's not so good for you and also create gases that warm the climate. And so if you were able to reduce the emissions of from fossil fuels or stop burning fossil fuels altogether, then this would be... This would be a good thing for climate change and for air quality and for health. And all of these benefits that we get from this, we call this co-benefits, multiple benefits of interventions, where you sort of you can kill two birds with one stone or actually multiple birds with one stone(although that's not so good for the biodiversity goal, might I add.) And so that's one important part of the story. Another important part of the story is, so while a lot of things that we do that pollute air come from fossil fuels, there's also like some things that we do that don't necessarily generate a lot of carbon dioxide. So the cookstoves story is actually one of them. Other ones include things like diesel fuel. So these are diesel powered engines... Like, diesel actually is, compared to regular petroleum - it's more efficient. So it can actually have a good impact on, if you're comparing the diesel-powered vehicle to a gas- powered vehicle, at least in theory, it will reduce your CO2. It's more efficient. But the problem is that, especially in developing country contexts and even in some developed countries too, diesel produces more particulate matter. It produces more of these fine particles that's not so good for you, especially if it's burned without filters on the tailpipe. They call it diesel particulate filters. And in developing countries, a lot of times, they don't have filters on there because you need to have high-quality fuel to use these filters. So part of the story is that diesel and cookstoves and, to some extent, the burning of biomass in like fields, the burning of crop residue, also the creation of bricks, brick kilns. These things all create black carbon. It gets a little bit confusing, but anyways, black carbon leads to warming in the climate in the near term as opposed to the CO2. CO2 can sit up in the atmosphere for about 100 to 1000 years or so, but the black carbon sometimes is like seven days to 14 days or so, and it goes up there for a real short period of time and it absorbs a lot of heat in that real short period of time and leads to real intense warming and in a short period of time, exacerbating or making worse the existing climate change. And so, you know, if I had a chance to do it over again, I would put a lot more emphasis on these - we call them short lived climate pollutants (SLCPs), like the black carbon that comes from the particulates as well as- and that's sort of a call that sort of a more air pollution focused co-benefits approach, as well as a more conventional co-benefits approach which might focus more on reducing fossil fuels (a good thing for long term climate change, and then also get some reductions in other air pollutants). And all of this type of story, though, is really missing from the SDGs. So once again, if I had a chance to do it again, I would put some more emphasis on these type of interlinkages. A third set of interlinkages is also- they're looking more and more at the relationship when climate is warmer. How does that lead to changes in air quality and how does that make air quality more dangerous or air pollution more dangerous? So you have hotter weather and makes it more difficult for people to breathe, and, you know. And so these type of interlinkages, I think, are really sort of missing. And some of the trade offs that André mentioned, too, I think are, to some extent, missing. So, yeah, these are some of the things that I would focus on. The natural place to that I think to work on this is the WHO- the World Health Organization just released a new set of air quality guidelines, which are- last year, and they're much stronger on many of the key pollutants than the previous ones, which were in 2005 or 2006, so almost 15 years ago. The natural starting point for me, if we were going to do on air quality or atmospheric pollution goal, would be to draw onto these draw upon these new guidelines. So for instance, the guideline- there's different parts of the guideline - but the recommended guideline for particulate matter 2.5 (for fine particulates) used to be 50 micrograms per cubic metre, and now that's down to five micrograms per cubic metre. If we had that type of guideline, incidentally, almost 99% of the world doesn't achieve that guideline right now.

Erin: 59:11

Yeah.

Eric: 59:12

So the closest is Australia and Oceania, which is around like seven micrograms per cubic metre. So if we had those type of guidelines, I think it's aspirational of course, and developing countries would be- really struggle to get anywhere close to that. But maybe there could be some- there are some interim targets, so maybe you could have a more tiered structure for different countries at different levels of development. But I think that would be something that could have huge impacts on health. And I mean, the interesting thing is even at very, very low levels of concentrations of PM2.5, there are health impacts and recent studies are showing that even if you go from one microgram to two micrograms, there's a more or less a linear relationship between the health impacts and that even at those very, very low levels. So...

Erin: 59:58

Yeah, that's an important point. Yeah. I just wanted to do like a wrap up question, which is that the UN General Assembly passed a resolution in late July this year where they recognised health as a human right. And this is not a legally binding document by any means, but it's more about norms setting and hopefully nudging governments to do the right thing. And I guess my question is, how will this make a difference if it will make a difference?

Eric: 1:00:30

Yeah. So that's an interesting question, Erin. I mean, I think, you know, this framing of different issues and themes as a human right is trying to appeal to the better senses of different governments to get them to do the right thing. And I think you're right that this is partially an effort to do some of this norms setting. And I think it might have some implications for, for instance, a post-2030 SDGs as we see a gradual effort to make stronger linkages between environmental concerns, health concerns and human security. I think, you know, what we've seen with Ukraine and COVID has really put a lot of emphasis on trying to appeal to this security framing in a way that will make linkages between these different issues so that you'll get less Ukraine type of interventions and more interventions that protect the security of human beings and in some ways, you know, subsuming national interest for human interests. And so I think that that has some potential to do that. I think about... You know, I was watching the news the other day and there was a short documentary on what's happened in Afghanistan after the US left and the Taliban has retaken control. And they were interviewing a woman who works in a hospital in Kabul and she was basically explaining that, you know, there's been a lot of interest in trying to reinvest in education, agriculture... but she's one of the few women, actually, that's still able to work in this 'new' Afghanistan, if you will. But her contention was that,"the first thing we need to do is take care of the medical system and people's health, because if we don't have that, then all of these other things we really can't even think about, like education or some of the other initiatives that are moving forward". So I wonder, you know, if by trying to make some linkages between human rights and health, as in making health a sort of fundamental human right, could appeal to some of these governments that are disconnecting those things in some ways. And so I think that, you know, changing those norms and putting it in those terms might have some influence even at the national and local level where we need some of these changes to happen. Those are just some thoughts for myself.

Erin: 1:03:17

Thank you.

André: 1:03:18

I guess we'll get onto - I forget which SDG it is, but - I think there are a couple of where human rights in general might stand out a little bit more than this one. So it'll be interesting if it comes up again. But like yeah, this is maybe just a rhetorical question. You know, the question of what does a right- what does it mean to say that something is a human right? I would- my contention would be is that it's meaningless unless it's backed up by the ability to enforce it. And I know that sounds a little bit militant, but unfortunately, that's kind of more or less what it boils down to. Or if everyone agrees, everyone in the society agrees on it. But, you know, this would be kind of be one or the other. So I didn't know about that particular... Was it the UN or was it the WHO-

Erin: 1:04:03

UN. UN General Assembly resolution.

André: 1:04:06

Right. Yeah. So I guess the question is kind of, you know, to what extent it'll be adopted at the national level, which is really where it matters as far as that kind of thing is concerned. Yeah. But I guess it's good that people at least thinking in that direction.

Bob: 1:04:27

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